A 59-year-old morbidly obese woman with a history of congestive heart failure presented with three days of intermittent chest discomfort. She characterized it as heartburn—a mid-epigastric burning sensation radiating up her neck. It was not associated with exertion, lasted an hour or two, and resolved with antacids. The patient poorly tolerated exercise at baseline, and was able to walk only short distances around her home for the past several years. She stated that these symptoms had been worsening over the past week, but she denied chest pain on exertion, orthopnea, or paroxysmal nocturnal dyspnea.

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